Kansas Preferred Insurance Group Auto Quote Sheet
913-585-1981 34102 Commerce Dr Ste B De Soto, KS 66018 www.kpigroup.net
Client Name:
*
First Name
Last Name
Date of Birth
*
Driver's License Number
*
Spouse Name:
*
First Name
Last Name
Date of Birth
*
Driver's License Number
*
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
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New Mexico
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North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number:
*
Email Address:
*
SMS Communication Consent:
Auto Information
Effective Date:
*
-
Month
-
Day
Year
Date
Current Insurance Company:
*
Policy Term Length:
*
Please Select
6 Months
12 Months
Billing Schedule:
*
Please Select
Monthly
Pay In Full
Auto Coverages
Bodily Injury Limit:
*
Please Select
100,000/300,000
300,000/300,000
250,000/500,000
500,000/500,000
Property Damage:
*
Please Select
100,000
250,000
300,000
500,000
Underinsured/Uninsured Motorist:
*
Please Select
100,000/300,000
300,000/300,000
250,000/500,000
500,000/500,000
Good Student Discount?
Please Select
Yes
No
Collision Deductible:
*
Please Select
$250
$500
$1000
N/A
Comprehensive Deductible:
*
Please Select
$250
$500
$1000
N/A
Vehicle 1: VIN Number
*
Vehicle 1: Coverage Requested
*
Full Coverage
Liability Only
Rental Car Coverage
Towing Coverage
Vehicle 2: VIN Number
Vehicle 2: Coverage Requested
Full Coverage
Liability Only
Rental Car Coverage
Towing Coverage
Vehicle 3: VIN Number
Vehicle 3: Coverage Requested
Full Coverage
Liability Only
Rental Car Coverage
Towing Coverage
Vehicle 4: VIN Number
Vehicle 4: Coverage Requested
Full Coverage
Liability Only
Rental Car Coverage
Towing Coverage
Vehicle 5: VIN Number
Vehicle 5: Coverage Requested
Full Coverage
Liability Only
Rental Car Coverage
Towing Coverage
Additional Drivers
Please include Date of Birth & Driver's License Numbers for All additional Drivers
Name:
First Name
Last Name
Date of Birth
Driver's License Number
Name:
First Name
Last Name
Date of Birth
Driver's License Number
Name:
First Name
Last Name
Date of Birth
Driver's License Number
Name:
First Name
Last Name
Date of Birth
Driver's License Number
Describe any losses or claims in the past 5 years.
Submit
Should be Empty: